Email email@example.com or tweet @pimpedmed with comments, questions, and episode ideas. Pimped-Ob/Gyn is a podcast aimed at medical, PA, and NP students who are entering their clinical rotation in Ob/Gyn. It covers topics including Your Ob/Gyn Survival Guide-Tips and Tricks, Labor and Delivery, Vaginal deliveries, C-sections, Hysterectomies and more. Each podcast walks you through a portion of what you’ll experience during your clinical rotations, gives you tips for excelling, preps you for the Pimping that’ll occur and sets you up to overall Honor the rotation!
Cervical: Age 21-65 Cytology q3yrs, co-test q5 if normal.
ASCCP guidelines (there is an app! Or PDF: http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-management-guidelines-august-2014-pdf )
Breast: ACOG: 40-75 annual mammogram
Colon: Colonoscopy, FOBT, FIT. Begin at age 50. If first degree relative with colon cancer begin screening at age 40 or 10yrs prior to youngest diagnosis, whichever is younger.
Lung: 55-80 with 30pack-year hx, annual low-dose CT
HPV: 3 dose series age 12-26
Pneumovax: 1 dose and 1 booster any age if risk factors. After age 65 if no risk factors
Shingles: 2 dose age 50+
Hep B: initial vaccination in youth, vaccination for anyone non-immune
MMR: if not immune
Varicella: if not immune
Tdap: Booster at 10yrs, new parents
Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1
Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin
Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once.
HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed.
Syphilis: Painless chancre followed by latent, then secondary with palmar/plantar rash. If unsure stage, treat as if latent, PCN IM x3
HIV: Universal screening. PREP if high risk. Referral to ID and counseling if positive.
Hep B: Treatable, not curable. Routine serum screening.
No Routine Screening, diagnose if lesion
HSV: Antivirals as needed for outbreaks, can prophylax if frequent outbreaks/immunosuppressed. Valacyclovir or acyclovir are most common.
Why: ASCCP guidelines (there is an app! Or PDF)
Cervical dysplasia — caused by HPV
CIN I–CIN3 is a progression
Risk factors: Smoking, other STIs including HIV, immunodeficiency
Histology: Increased Nuclear: cytoplasmic ratio when abnormal
Acetic Acid: exact mechanism unknown, the higher N:C ratio cells (aka abnormal cells) reflect more light and appear white.
Lugols: Iodine rich-reacts with glycogen in normal squamous cells so they appear dark. Non-staining cells are abnormal.
HPV — changes
Increased vascularity, punctations, mosaicism, surface contour changes
Stain abnormality and know where abnormal biopsy was taken
Single pass is ideal–tag a side for orientation
+/- Top Hat depending on ECC result
Higher up in cervical canal, but more complications
No electricity– okay if pregnant
Doptones, fundal height, vitals
Four question: Vaginal bleeding, contractions, leaking fluid, fetal movement
20wks – get and review anatomy US
24wks – order glucola, cbc (check for anemia), discuss normal growing pains
28wks – Tdap and Rhogam if needed, discuss kick counts
32wks – Discuss BCM, sign tubal papers if needed, discuss TOLAC if needed
36wks – GBS screening, birth expectations, US for position
38-40wks – VE, “sweep membranes”
Options counseling if needed
Ultrasound for dating
Screening options: QUAD, Sequential, NIPS, invasive testing
BMI under 18.5 should gain 28–40 pounds.
Normal-weight women (BMI, 18.5–24.9) should aim for 25–35
Overweight women (BMI, 25–29.9) should aim for 15–25
Obese women (BMI, 30 or more) should gain only 11–20
Food: Avoid unpasteurized dairy, large fish (swordfish, shark, king mackerel, tilefish, bigeye tuna etc), uncooked meat/seafood, uncooked deli meat, EtOH
Drugs: Nothing unless cleared by MD. Tylenol okay if needed, PNV, Colace, FeSO4. NO NSAIDs!
Exercise: Nothing that could leave a bruise on your belly! Moderate exercise is great.
Hysteroscopy = looking inside the uterus with a scope
Dilate the cervix
Distend the uterus with fluid
Look around, identify pathology, identify tubal ostia, remove pathology if using an operative scope or Myosure or another resectoscope.
Feared complication: Hyponatremia from excessive hypotonic fluid absorption.
Differential diagnosis for Temp >38.0C
Epidural fever (transient), DVT/PE (if prolonged IOL or limited mobility), UTI, Intraamniotic infection (with or without ROM), etc
Chorioamnionitis aka IAI aka Triple-I (intrapartum intraamniotic Infection)
One temp >39.0C
One temp 38.0C-39.0C AND one or more risk factors
Two temps >38.0C 30+ mins apart
Tx: the standard is Ampicillin/Gentamycin until delivery. Tylenol prn temp>38C, IVF for maternal/fetal tachycardia, cooling blanket if needed to decrease temp.
If mild PCN allergy: Ancef/Gent
If severe PCN allergy: gent/clinda or gent/vanc
If vaginal delivery: No evidence that continued abx postpartum provide benefit.
If c-section: Add clindamycin to Amp/Gent.
Continue at least 1 dose postpartum. Clinical judgment on when to d/c. Some do 1 dose, some 24hrs afebrile, until clinical improvement, etc.
Wind – PNA, atelectasis, URI
Womb – Endomyometritis — Gent/Clinda x 24hrs afebrile
Wound – Superficial wound infection, cellulitis — eval for collection, probe wound/fascia if able
Water – UTI, Pyelo — get UA
Walking – DVT/PE
Weening – Engorgement or mastitis
Nonreassuring fetal heart tracing
Category 2-remote from delivery
Minimal/absent variability is most significant predictor of fetal acidemia
Category 3 any time is emergent deliver
Many different definitions: Most commonly 12-24hrs ruptured membranes on pitocin without active labor
Arrest of dilation
Can only meet criteria once in active labor 6cm or greater
Do you know if her contractions are adequate? IUPC with MVUs>200-250
If the contractions are adequate, no change over 4hrs
If contractions are inadequate or no IUPC, no change over 6hrs
Arrest of descent
Prime with epidural 3hrs
Prime without epidural-2hrs
Mutlip with epidural 2hrs
Multip without epidural 1hr
-Breech, transverse, compound
What approach: Abdominal, laparoscopic, vaginal or combination
Taking or leaving the tubes and ovaries?
Tubes: What benefit do they provide? Risk?
Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off
If it’s laparoscopic–listen to the LSC podcast for more details on the approach
Let’s talk about important steps:
The round ligament: What artery runs inside the round? Sampson’s.
What structure conceals the blood flow to the ovary? The IP ligament (formerly the suspensory ligament of the ovary). The artery comes from the aorta, so if this is transected before it is fully sealed, it can hemorrhage while retracting back into the retroperitoneum. Badness!
What are the four levels at which the ureter is injured during hysterectomy? 1- At the pelvic brim, 2- medial to the IP ligament, 3- as it passes under the uterine artery (water under the bridge) and 4- lateral to the vaginal cuff closure.
Ligate and transect the uterine arteries–the uterus should blanch white.
Colpotomy– disconnecting uterus from vagina
Close vaginal cuff if total hyst
Review anatomy– you’ll be able to see well!
Pimped- Youtube Channel videos for laparoscopic anatomy
What case are you doing and why?
Review common indications, steps to procedure and potential risks/complications
Saying hi to the patient first
Being helpful setting up — yellowfins or stirrups for lithotomy
Scrubbing in — ask to grab your gown/gloves for the scrub, open carefully or get help if unsure
Abx: If entering uterus or vagina ie hyst
Prep: infection prevention with chloraprep or something
EtOH based, needs to evaporate before draping or risk fire!
Vaginal prep — betadine or chlorhexidine
Then everyone scrubs
Let resident/attending drape unless asked.
You may be asked to help with foley/manipulator
Uterine manipulators: Many sizes/shapes/types
Vagina is dirty– can’t go from vagina to abdomen
Entry: Typically in umbilicus or just above. Can use Palmer’s Point if needed.
Direct visualization with Hassan
Insufflate with CO2
Port placement: Typically middle ⅓ of distance between ASIS and umbilicus. Avoid obvious superficial vessels and inferior epigastric –watch from below
Dx LSC– endometriosis, adhesions
Tubal ligation or bilateral salpingectomy
Closing ports: Close fascia on ports >5mm due to increased risk of hernia
Post-op checks: Many LSC cases are same-day, meaning patients go home
-Nausea/vomiting, eating/drinking, voiding, passing flatus, ambulating
Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation
In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective
Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout.
Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed.
Hysterotomy — lower uterine segment, lateral uterine vessels to avoid
Delivery baby — delay cord clamp, placenta
Likely lots of bleeding — same atony meds as vaginal delivery
Clean inside of uterus to remove all membranes etc.
Possibly exteriorize uterus to see better — depends on scaring
How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures.
Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis.
Clean up the abdomen–irrigation vs moist laps vs suction
Now to close:
Peritoneium — either way, close or not– no evidence either way
Muscle– don’t close, evidence that closing it can cause hematoma
Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric
Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection
Skin closure — stables, suture, absorbable stables
The OB One-Liner: “This is a _ yr old G_ P_ @_ wks GA here for ____.”
Ex: This is a 34yo G3P2002 @ 38wks3days GA here for contractions
Triage: 4 essential questions to ask every pregnant woman in triage
Contractions, leaking fluid, vaginal bleeding, fetal movement
What is labor? Cervical change and contractions
Evaluate for ROM: Pooling, nitrazine (pH), ferning.
Vaginal bleeding—when do we care? 2nd or 3rd trimester worry about placenta: abruption, previa, vasa previa
DFM: NSTs, BPPs, Kick counts
High yield resources and tips for your Ob/Gyn clerkship.
Youtube Playlist: http://bit.ly/pimped-ob
Obstetrics and Gynecology by Beckmann
Pimped App – Clinical questions to expect in the OR and on the wards
LactMed – medications safe in breastfeeding
ASCCP: Cervical cancer screening
CDC STI guidelines
OB Wheel or dating
Tips and Tricks:
Be Proactive—talk to students who just finished the rotation about ways to be helpful and the day to day logistics.
Expectations: Ask for them to be set at the beginning. Clarify as needed.
Be Self-sufficient, but ask for help when appropriate
Before leaving for the day, ask when you should come in to round, who to pre-round on and where to meet.
Once or twice a week ask for feedback when everyone has a down moment.
Labor and Delivery:
Gs & Ps aka Gravity and Parity.
Gestational age Preterm vs term